Gastroskopide tesadüfen tanınan diffüz büyük B hücreli karaciğer lenfoması: Vaka sunumu


Hepatic diffuse large B-cell lymphoma incidentally diagnosed during gastroscopy: A case report


1Ahmet Burak TOROS, 2Hüseyin YAŞAR, 3Mehmet Mustafa ÖZLÜ, 4Beşir KESİCİ

Departments of, 1Gastroenterohepatology, 2Internal Diseases, 3Radiology, Medistate Kavacik Hospital, Istanbul, Turkey
4Department of Internal Diseases, Bahçeşehir University, Medical School Istanbul, Turkey


Anahtar Kelimeler: Primer karaciğer lenfoması, non-Hodgkin lenfoma, karaciğer, gastroskopi

Keywords: Primary hepatic lymphoma, non-Hodgkin lymphoma, liver, gastroscopy

Makale PdfEndoskopi künye


Özet

Karaciğerin primer non-Hodgkin lenfoması, oldukça nadir görülür. Bu yazı- da; son 6 aydır yorgunluk-hafif kilo kaybı-iştahsızlık yakınmaları olan 78 ya- şındaki bir erkek hastanın vaka sunumunu yapıyoruz. Hasta anemik olduğu ve düzenli aspirin kullanım öyküsünden dolayı, öncelikle mideden kronik kan kaybı olasılığını düşünerek, bir gastroskopi yapmayı planladık. Gastroskopide; büyük kurvatura üzerinde hareketli, yarım küre şeklinde bir dış bası izi görerek; bir sonraki basamak olarak kontrastlı tüm batın tomografisi çektirdik. Batın tomografisinde; çok sayıda kitle lezyonlarının sebep olduğu, büyümüş bir karaciğer saptandı. Yapılan pozitron emisyon tomografisinde yaygın lenf nodu tutulumu olan, assite sebep olmuş muhtemel bir malignite tespit edildi. Ultrasonografi eşliğinde karaciğer biyopsisi gerçekleştirildi, patolojik tanı karaciğerin yaygın büyük B hücreli lenfoması olarak geldi. Hasta şu anda medikal onkolojinin takibinde olup, kemoterapi seanslarına girmektedir. Umarız ki yazımız, gastroskopi yapan meslektaşlarımızda, işlem sırasında saptanan böyle bir dış basının altından ilginç tanılar çıkabileceğine dair farkındalık yaratır.


Abstract

Primary non-Hodgkin lymphoma of the liver is a very rare malignancy. Here, we report the case of a 78-year old man who presented with complaints of fatigue, slight weight loss and decreased appetite; since 6 months. Because he was anemic and regularly taking aspirine, we first suspected chronic blood loss from the stomach as a cause of anemia. Gastroduodenoscopy was planned as the next step. It revealed an external hemispheric, mobile compression on the greater curvatura of the stomach; which had to be further evaluated via whole abdominal computed tomography with contrast Abdominal computed tomography demonstrated hepatomegaly caused by multiple mass lesions, with necrosis at the center. Next, a positron-emission tomography was advised; and it revealed potential malignacy with widespread lymph node metastases and malignant ascites. Liver biopsy performed under ultrasonographic guidance revealed diffuse large B-cell lymphoma of the liver. The patient is now under medical oncology follow-up, and receiving chemotherapy. Based on our findings, physicians should be more aware and consider that external gastric compression on routine gastroscopy may be an indicator of a more serious disease.


Giriş

Primary hepatic lymphoma (PHL) is an unusual form of non-Hodgkin lymphoma (NHL) that usually presents with constitutional symptoms, hepatomegaly and signs of cholestatic jaundice without lymph node and extrahepatic (spleen, bone marrow and other lymphoid tissues) metastases at early stage of the disease (1). The prevalance of PHL was 0.4% among extranodal non-Hodgkin lymphomas, and 0.016% among all non-Hodgkin lymphomas (2). PHL may ocur at any age, although the median age is 50 years, with a maleto-female ratio of 2/3:1 (3-5). The etiology of PHL remains unclear, however, certain viruses, including hepatitis C virus (HCV), human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) may be involved. Liver cirrhosis, systemic lupus erythematosus (SLE) and immunosupressive therapy may also be associated with PHL. HCV infection is detected in 40 %-60 % of patients with PHL (2,6,7). To date, no optimal treatment for PHL exists due to the rarity of this malignancy. However, surgical resection, radiotherapy and chemotherapy are the currently available treatment modalities. Here we present a patient who had an external mass compressing into the gastric lumen, as observed on routine gastroscopy, but was later diagnosed as diffuse large B-cell lymphoma of the liver.


Olgu

A 78-year old man presented at our outpatient clinic with complaints of fatigue, slight weight loss and decreased appetite; since 6 months. His physical examination revealed no pathological finding, except epigastric pain. His medical history included diabetes, hypertension and ischemic cardiovascular disease, for which he was undergoing regular treatment. Blood tests revealed normochromic normocytic anemia with moderate neutropeni; other parameters were within normal limits. Because he was taking clopidogrel and acetylsalicylic acid (ASA) daily for ischemic heart disease, we first suspected chronic blood loss from the stomach, hence gastroduodenoscopy was planned as the next investigative step. Endoscopy revealed reflux esophagitis, pangastritis with duodenitis, along with an external hemispheric and mobile compression on the greater curvatura of the stomach, thus necessitating a whole abdominal computed tomography (CT) with contrast as the next step in investigation. Abdominal CT revealed hepatomegaly caused by multiple mass lesions, with necrotic centers. A PET/CT was advised; which revealed potential malignacy with widespread lymph node metastases and malignant ascites. A liver biopsy was performed under ultrasonographic guidance, which revealed diffuse large B-cell lymphoma of the liver. The patient is now under medical oncology follow-up, and undergoing chemotherapy.


Gereç ve Yöntem


Bulgular


Sonuçlar


Tartışma

PHL was first described in 1965 by Ata and Kamel (8). It is described as a lymphoma which is either confined to the liver or majorly involving the liver (9). It represents less than 1% of all extranodal lymphomas (10). Based on histological and immununohistochemical data, different subtypes of primary lymphoma of the liver have been described. The most common variant of NHL of the liver is diffuse large B-cell lymphoma, which accounted for 71% of all PHL cases in a previous study (11). The exact cause of PHL is unknown, although viruses such as HBV, HCV and Ebstein Barr virüs have been implicated. There may be a strong association between primary hepatic NHL and HCV. Hepatitis C is found in 40%-60% of patients with PHL. The possible roles of HCV, cirrhosis and therapeutic interferon in lymphomagenesis remain unclear (12). However, our patient was not positive for HCV or HBV. PHL is twice as frequent in men as in women and the usual age at presentation is 50 years (9). Symptoms are usually nonspesific, with most patients reporting right upper quadrant and epigastric pain, fatique, weight loss, fever, anorexia and nausea, hepatomegaly is also frequently encountered (13). The disease may be of either T or B-cell origin. Most PHLs corresponds to a larger cell type and demonstrates a B-cell immunophenotype (14). Symptoms and histological features are very typical for the disease, as in our case. Liver biopsy remains the most valuable tool for the diagnosis of PHL, which was also used in our case to achieve correct diagnosis. The patient is now under medical oncology follow-up, and receiving chemotherapy. Notably, PHL should be considered as the differential diagnosis when examining patients with space-occupying liver lesion. These lesions can sometimes cause external compression of the stomach, which highligts the importance of gastroscopy in the diagnosis of such distinct lesions. We hope that our case study increases awareness among our colleagues about considering an external gastric compression on routine gastroscopy as a sign of a more serious disease.


Kaynaklar

1. Caccamo D, Pervez NK, Marchevsky A. Primary lymphoma of the liver in the acquired immunodeficiency syndrome. Arch Pathol Lab Med 1986;110:553-5. 2. Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of extranodal lymphomas. Cancer 1972;29:252-60. 3. Resende V, Oliveira TS, Gomes RT, et al. Primary hepatic lymphoma: a case report. Int J Surg Case Rep 2013;4:1165-8. 4. Raimondo L, Ferrara I, Stefano AD, et al. Primary hepatic lymphoma in a patient with previous rectal adenocarcinoma: a case report and discussion of etiopathogenesis and diagnostic tools. Int J Hematol 2012;95:320-3. 5. Lei KI. Primary non-Hodgkin’ s lymphoma of the liver. Leuk Lymphoma 1998;29:293-9. 6. Trneny M, Salkova J, Dlouha J, Stritesky J. Hepatic involvement in patients with non-Hodgkin’ s lymphoma. Vnitr Lek 2013;59:606-11. 7. Kikuma K, Watanabe J, Oshiro Y, et al. Etiological factors in primary hepatic B-cell lymphoma. Virchows Arch 2012;460:379-87. 8. Ata AA, Kamel IA. Primary reticulum cell sarcoma of the liver: a case report. J Egypt Med Assoc 1965;48:514-21. 9. Haider FS, Smith R, Khan S. Primary hepatic lymphoma presenting as fulminant hepatic failure with hyperferritinemia: a case report. J Med Case Report 2008;2:279. 10. Agmon-Levin N, Berger I, Shtalrid M, et al. Primary hepatic lymphoma: a case report and review of the literature. Age Aging 2004;33:637-40. 11. Bronowicki JP, Bineau C, Feugier P, et al. Primary lymphoma of the liver: clinical-pathological features and relationship with HCV infection in French patients. Hepatology 2003;37:781-7. 12. Masood A, Kairouz S, Hudhud KH, et al. Primary non-Hodgkin lymphoma of the liver. Curr Oncol 2009;16:74-7. 13. Cameron AM, Truty J, Truell J, et al. Fulminant hepatic failure from primary hepatic lymphoma: successful treatment with orthotropic liver transplantation and chemotherapy. Transplantation 2005;80:993-6. 14. Bauduer F, Marty F, Gemain MC, Dulubac E, Bordahandy R. Primary non-Hodgkin’ s lymphoma of the liver in a patient with hepatitis B, C, HIV infections. Am J Hematol 1997;54:265.